Individualized blood pressure targets in the postoperative care of patients with intracerebral hemorrhage

2021 ◽  
pp. 1-10
Author(s):  
Anna Lindner ◽  
Verena Rass ◽  
Bogdan-Andrei Ianosi ◽  
Alois Josef Schiefecker ◽  
Mario Kofler ◽  
...  
Keyword(s):  
Blood Pressure ◽  
Intracerebral Hemorrhage ◽  
Brain Tissue ◽  
Scale Score ◽  
Cerebral Metabolism ◽  
Cerebral Microdialysis ◽  
Early Management ◽  
Poor Grade ◽  
Intracerebral Pressure ◽  
Icu Discharge

OBJECTIVE Recent guidelines recommend targeting a systolic blood pressure (SBP) < 140 mm Hg in the early management of patients with spontaneous intracerebral hemorrhage (ICH). The optimal SBP targets for ICH patients after hematoma evacuation (HE) remain unclear. Here, the authors aimed to define the optimal SBP range based on multimodal neuromonitoring data. METHODS Forty poor-grade ICH patients who had undergone HE and then monitoring of intracerebral pressure, brain tissue oxygen tension (PbtO2), and cerebral metabolism (via cerebral microdialysis [CMD]) were prospectively included. Episodes of brain tissue hypoxia (BTH) (1-hour averaged PbtO2 < 20 mm Hg) and metabolic distress (CMD–lactate/pyruvate ratio [LPR] ≥ 40) were identified and linked to corresponding parameters of hemodynamic monitoring (SBP and cerebral perfusion pressure [CPP]). Multivariable regression analysis was performed using generalized estimating equations to identify associations between SBP levels, PbtO2, and brain metabolism. RESULTS The mean patient age was 60 (range 51–66) years and the median [IQR] initial ICH volume was 47 [29–60] ml. In multivariable models adjusted for Glasgow Coma Scale score, probe location, ICH volume, and age, lower SBP was independently associated with a higher risk of BTH (≤ 120 mm Hg: adjusted OR 2.9, p = 0.007; 120–130 mm Hg: adj OR 2.4, p = 0.002; 130–140 mm Hg: adj OR 1.6, p = 0.017) compared to a reference range of 140–150 mm Hg at the level of the foramen interventriculare Monroi, which corresponded to a CPP of 70–80 mm Hg and SBP levels between 150 and 160 mm Hg at the heart level. After exclusion of episodes with mitochondrial dysfunction, SBP targets < 140 mm Hg were associated with higher odds of cerebral metabolic distress (≤ 130 mm Hg: OR 2.5, p = 0.041; 130–140 mm Hg: OR 2.3, p = 0.033). Patients with a modified Rankin Scale score ≥ 5 at neurological ICU discharge more often exhibited BTH than patients with better outcomes (51% vs 10%, p = 0.003). CONCLUSIONS These data suggest that lower SPB and CPP levels are associated with a higher risk for BTH. Further studies are needed to evaluate whether a higher SPB target may prevent BTH and improve outcomes.

scholarly journals A proteomic investigation of protein adsorption to cerebral microdialysis membranes in surgically treated intracerebral hemorrhage patients

2020 ◽  
Author(s):  
Lovisa Tobieson ◽  
Zita Czifra ◽  
Karin Wåhlén ◽  
Niklas Marklund ◽  
Bijar Ghafouri
Keyword(s):  
Intracerebral Hemorrhage ◽  
Human Brain ◽  
Protein Adsorption ◽  
Brain Tissue ◽  
Cerebral Microdialysis ◽  
Invasive Technique ◽  
Human Brain Tissue ◽  
Protein Patterns ◽  
Molecular Weight Range ◽  
Two Dimensional Gel Electrophoresis

Abstract Background: Cerebral microdialysis (CMD) is a minimally invasive technique for sampling the interstitial fluid in human brain tissue. CMD allows monitoring the metabolic state of tissue, as well as sampling macromolecules such as proteins and peptides. Recovery of proteins or peptides can be hampered by their adsorption to the CMD membrane as has been previously shown in-vitro, however, protein adsorption to CMD membranes has not been characterized following implantation in human brain tissue. Methods: In this paper, we describe the pattern of proteins adsorbed to CMD membranes compared to that of the microdialysate and of cerebrospinal fluid (CSF). We retrieved CMD membranes from three surgically treated intracerebral hemorrhage (ICH) patients, and analyzed protein adsorption to the membranes using two-dimensional gel electrophoresis (2-DE) in combination with nano-liquid mass spectrometry. We compared the proteome profile of three compartments; the CMD membrane, the microdialysate and ventricular CSF collected at time of CMD removal. Results: We found unique protein patterns for each of the three compartments, particularly in the molecular weight range of 10–35 kDa. Conclusion: This study highlights the importance of analyzing the membranes in addition to the microdialysate when using CMD to sample proteins for biomarker investigation.

scholarly journals Intracerebral Pro-inflammatory Cytokine Increase in Surgically Evacuated Intracerebral Hemorrhage - an Observational Microdialysis Study

2021 ◽  
Author(s):  
Lovisa Tobieson ◽  
Anna Gard ◽  
Karsten Ruscher ◽  
Niklas Marklund
Keyword(s):  
Intracerebral Hemorrhage ◽  
Brain Tissue ◽  
Inflammatory Cytokines ◽  
Inflammatory Mediators ◽  
Inflammatory Cytokine ◽  
Tissue Injury ◽  
Treatment Options ◽  
Cerebral Microdialysis ◽  
Cytokines And Chemokines ◽  
Anti Inflammatory

Abstract Background: Treatment options for spontaneous intracerebral hemorrhage (ICH) are limited. A possible inflammatory response in the brain tissue surrounding an ICH may exacerbate the initial injury and could be a target for treatment. Methods: In this observational study, ten patients needing surgical evacuation of supratentorial ICH received two cerebral microdialysis (MD) catheters; one in the perihemorrhagic zone (PHZ), and one in non-eloquent cortex (SNX) remote from the ICH. The microdialysate was analysed for energy metabolites (including lactate/pyruvate ratio (LPR) and glucose) and for inflammatory mediators using a multiplex immunoassay of 27 cytokines and chemokines at 6-10 hours, 20-26 hours and 44-50 hours after surgery. Results: Deranged energy metabolic markers suggestive of a metabolic crisis were found in PHZ compared to SNX, persistent throughout the 50 hours. Pro-inflammatory cytokines IL-8, TNF-α, IL-2, IL-1β, IL-6 and IFN-γ, anti-inflammatory cytokine IL-13, IL-4, and VEGF-A were significantly higher in PHZ compared to SNX, most prominent at 20-26 hours following ICH evacuation.Conclusions: Higher levels of pro- and anti-inflammatory cytokines in the perihemorrhagic brain tissue suggests a role for inflammatory mediators involved in secondary injury cascades potentially exacerbating tissue injury, which may constitute a target for future medical interventions.

scholarly journals Intracerebral Proinflammatory Cytokine Increase in Surgically Evacuated Intracerebral Hemorrhage: A Microdialysis Study

2021 ◽  
Author(s):  
Lovisa Tobieson ◽  
Anna Gard ◽  
Karsten Ruscher ◽  
Niklas Marklund
Keyword(s):  
Intracerebral Hemorrhage ◽  
Brain Tissue ◽  
Inflammatory Mediators ◽  
Treatment Options ◽  
Interferon Γ ◽  
Cerebral Microdialysis ◽  
Secondary Brain Injury ◽  
Study Objective ◽  
Surgical Evacuation ◽  
Anti Inflammatory

Abstract Background Treatment options for spontaneous intracerebral hemorrhage (ICH) are limited. A possible inflammatory response in the brain tissue surrounding an ICH may exacerbate the initial injury and could be a target for treatment of subsequent secondary brain injury. The study objective was to compare levels of inflammatory mediators in the interstitial fluid of the perihemorrhagic zone (PHZ) and in seemingly normal cortex (SNX) in the acute phase after surgical evacuation of ICH, with the hypothesis being that a difference could be demonstrated between the PHZ and the SNX. Methods In this observational study, ten patients needing surgical evacuation of supratentorial ICH received two cerebral microdialysis catheters: one in the PHZ and one in the SNX that is remote from the ICH. The microdialysate was analyzed for energy metabolites (including lactate pyruvate ratio and glucose) and for inflammatory mediators by using a multiplex immunoassay of 27 cytokines and chemokines at 6–10 h, 20–26 h, and 44–50 h after surgery. Results A metabolic crisis, indicated by altered energy metabolic markers, that persisted throughout the observation period was observed in the PHZ when compared with the SNX. Proinflammatory cytokines interleukin (IL) 8, tumor necrosis factor α, IL-2, IL-1β, IL-6 and interferon γ, anti-inflammatory cytokine IL-13, IL-4, and vascular endothelial growth factor A were significantly higher in PHZ compared with SNX and were most prominent at 20–26 h following ICH evacuation. Conclusions Higher levels of both proinflammatory and anti-inflammatory cytokines in the perihemorrhagic brain tissue implies a complex role for inflammatory mediators in the secondary injury cascades following ICH surgery, suggesting a need for targeted pharmacological interventions.

The effect of nimodipine on cerebral oxygenation in patients with poor-grade subarachnoid hemorrhage

2004 ◽  
Vol 101 (4) ◽  
pp. 594-599 ◽  
Author(s):  
Michael F. Stiefel ◽  
Gregory G. Heuer ◽  
John M. Abrahams ◽  
Stephanie Bloom ◽  
Michelle J. Smith ◽  
...  
Keyword(s):  
Blood Pressure ◽  
Subarachnoid Hemorrhage ◽  
Brain Tissue ◽  
Cerebral Oxygenation ◽  
Content Type ◽  
Poor Grade ◽  
Physiological Variables ◽  
Arterial Blood ◽  
End Tidal ◽  
Fine Print

Object. Nimodipine has been shown to improve neurological outcome after subarachnoid hemorrhage (SAH); the mechanism of this improvement, however, is uncertain. In addition, adverse systemic effects such as hypotension have been described. The authors investigated the effect of nimodipine on brain tissue PO2. Methods. Patients in whom Hunt and Hess Grade IV or V SAH had occurred who underwent aneurysm occlusion and had stable blood pressure were prospectively evaluated using continuous brain tissue PO2 monitoring. Nimodipine (60 mg) was delivered through a nasogastric or Dobhoff tube every 4 hours. Data were obtained from 11 patients and measurements of brain tissue PO2, intracranial pressure (ICP), mean arterial blood pressure (MABP), and cerebral perfusion pressure (CPP) were recorded every 15 minutes. Nimodipine resulted in a significant reduction in brain tissue PO2 in seven (64%) of 11 patients. The baseline PO2 before nimodipine administration was 38.4 ± 10.9 mm Hg. The baseline MABP and CPP were 90 ± 20 and 84 ± 19 mm Hg, respectively. The greatest reduction in brain tissue PO2 occurred 15 minutes after administration, when the mean pressure was 26.9 ± 7.7 mm Hg (p < 0.05). The PO2 remained suppressed at 30 minutes (27.5 ± 7.7 mm Hg [p < 0.05]) and at 60 minutes (29.7 ± 11.1 mm Hg [p < 0.05]) after nimodipine administration but returned to baseline levels 2 hours later. In the seven patients in whom brain tissue PO2 decreased, other physiological variables such as arterial saturation, end-tidal CO2, heart rate, MABP, ICP, and CPP did not demonstrate any association with the nimodipine-induced reduction in PO2. In four patients PO2 remained stable and none of these patients had a significant increase in brain tissue PO2. Conclusions. Although nimodipine use is associated with improved outcome following SAH, in some patients it can temporarily reduce brain tissue PO2.

Determinants and Prognostic Significance of Hematoma Sedimentation Levels in Acute Intracerebral Hemorrhage

2015 ◽  
Vol 41 (1-2) ◽  
pp. 80-86 ◽  
Author(s):  
Shoichiro Sato ◽  
Candice Delcourt ◽  
Shihong Zhang ◽  
Hisatomi Arima ◽  
Emma Heeley ◽  
...  
Keyword(s):  
Blood Pressure ◽  
Intracerebral Hemorrhage ◽  
Scale Score ◽  
Controlled Trial ◽  
Blood Pressure Reduction ◽  
Prognostic Significance ◽  
Logistic Regression Models ◽  
Elevated Systolic Blood Pressure ◽  
Acute Intracerebral Hemorrhage ◽  
Post Hoc

Background: This study aimed at identifying the determinants and prognostic significance of a sedimentation level (fluid-blood level) in the hematoma among patients with acute intracerebral hemorrhage (ICH) who participated in the main Intensive Blood Pressure Reduction in Acute Cerebral Hemorrhage Trial (INTERACT2). Methods: Post-hoc analysis of the INTERACT2 dataset, a randomized controlled trial of patients with acute ICH with elevated systolic blood pressure (SBP), randomly assigned to intensive (target SBP <140 mm Hg) or guideline-based (<180 mm Hg) BP management. Patients with a sedimentation level at baseline assessment on CT, and modified Rankin Scale score at 90-day, were included in these analyses. Factors associated with a sedimentation level and its significance in relation to 90-day clinical outcomes were assessed in univariable and multivariable logistic regression models. Results: Of 2,065 participants, 19 (1%) had sedimentation level on baseline CT, which was independently associated with warfarin use (p = 0.006) and lobar ICH (p = 0.025). Sedimentation level was also associated with death or major disability at 90-day in both crude (84 vs. 53%; p = 0.014) and multivariable analyses adjusted for age, gender, Chinese region, warfarin use, baseline National Institutes of Health Stroke Scale score, onset to CT time, volume and location of ICH, intraventricular extension, and randomized intensive BP lowering (OR 3.94, 95% CI 1.01-15.37; p = 0.049). Conclusions: The presence of hematoma sedimentation level on baseline CT is associated with warfarin use and lobar location of ICH, and predicts a worse outcome. Although uncommon, sedimentation level is an easily detectable prognostic factor in acute ICH.

scholarly journals A proteomic investigation of protein adsorption to cerebral microdialysis membranes in surgically treated intracerebral hemorrhage patients

2020 ◽  
Author(s):  
Lovisa Tobieson ◽  
Zita Czifra ◽  
Karin Wåhlén ◽  
Niklas Marklund ◽  
Bijar Ghafouri
Keyword(s):  
Intracerebral Hemorrhage ◽  
Human Brain ◽  
Protein Adsorption ◽  
Brain Tissue ◽  
Cerebral Microdialysis ◽  
Invasive Technique ◽  
Human Brain Tissue ◽  
Protein Patterns ◽  
Molecular Weight Range ◽  
Two Dimensional Gel Electrophoresis

Abstract Background Cerebral microdialysis (CMD) is a minimally invasive technique for sampling the interstitial fluid in human brain tissue. CMD allows monitoring the metabolic state of tissue, as well as sampling macromolecules such as proteins and peptides. Recovery of proteins or peptides can be hampered by their adsorption to the CMD membrane as has been previously shown in-vitro, however, protein adsorption to CMD membranes has not been characterized following implantation in human brain tissue. Methods In this paper, we describe the pattern of proteins adsorbed to CMD membranes compared to that of the microdialysate and of cerebrospinal fluid (CSF). We retrieved CMD membranes from three surgically treated intracerebral hemorrhage (ICH) patients, and analyzed protein adsorption to the membranes using two-dimensional gel electrophoresis (2-DE) in combination with nano-liquid mass spectrometry. We compared the proteome profile of three compartments; the CMD membrane, the microdialysate and ventricular CSF collected at time of CMD removal. Results We found unique protein patterns for each of the three compartments, particularly in the molecular weight range of 10-35 kDa. Conclusion This study highlights the importance of analyzing the membranes in addition to the microdialysate when using CMD to sample proteins for biomarker investigation.

Abstract T P315: Wake-up Intracerebral Hemorrhage Is Not Different From Intracerebral Hemorrhage With Known Onset Time

Stroke ◽  
2015 ◽  
Vol 46 (suppl_1) ◽  
Author(s):  
Joan Martí-Fàbregas ◽  
Luis Prats ◽  
Alejandro Martínez-Domeño ◽  
Rebeca Marín ◽  
Francesca Casoni ◽  
...  
Keyword(s):  
Risk Factors ◽  
Blood Pressure ◽  
Intracerebral Hemorrhage ◽  
Scale Score ◽  
Neurological Deficit ◽  
Onset Time ◽  
Vascular Risk Factors ◽  
Neurological Deterioration ◽  
Vascular Risk ◽  
Nihss Score

Background: The frequency of wake-up Intracerebral Hemorrhage (WU-ICH) is uncertain. It is also unknown whether there are clinical, radiological and prognostic differences between WU-ICH and non-WU-ICH. We assessed the hypothesis that both types of ICH do not differ. Methods: This is a multicentre (n=6 tertiary hospitals) registry of consecutive patients with ICH. We collected the following variables: Time of onset. WU onset was defined as stroke detected on awakening, independently of the time of the day; Demographics (age, sex); Traditional vascular risk factors; Severity of the neurological deficit at admission (NIHSS score and/or Glasgow coma scale score -GCS-); Neurological deterioration (decrease in >1 point in GCS and/or increase in >3 points in NIHSS score); Etiology; Neuroimaging at admission (location, secondary intraventricular hemorrhage, hematoma volume); Blood pressure, blood glucose, platelet count and INR at admission; and Outcome (modified Rankin scale score -mRS- at discharge and at 3 months; favourable outcome when mRS ≤ 2). Patients were treated according to national guidelines of ICH. Comparison between groups was achieved with Student’s t-test, Chi-square test and Mann-Whitney’s U test. Results: We included a total of 270 patients, whose mean age was 70.2 ± 14.4 years, and 60% of them were men. WU-ICH was diagnosed in 49 (18%) patients. We found no significant differences between groups in demographics, frequency of vascular risk factors, severity of the neurological deficit, etiology, blood pressure, blood analysis and neuroradiological findings. Patients with WU-ICH had a lower frequency of neurological deterioration when assessed by the NIHSS scale (p= 0.04) but not by the GCS scale. The outcome at discharge and at 3-months was equivalent between groups. Conclusions: In conclusion, 18% of ICHs are detected on awakening. Patients with wake-up ICH do not differ from patients with known onset time either in most clinical and radiological variables or in the long-term prognosis. WU-ICH patients may have a lower likelihood of neurological worsening within the acute stage.

scholarly journals Proteomic investigation of protein adsorption to cerebral microdialysis membranes in surgically treated intracerebral hemorrhage patients - a pilot study

2020 ◽  
Author(s):  
Lovisa Tobieson ◽  
Zita Czifra ◽  
Karin Wåhlén ◽  
Niklas Marklund ◽  
Bijar Ghafouri
Keyword(s):  
Intracerebral Hemorrhage ◽  
Human Brain ◽  
Protein Adsorption ◽  
Brain Tissue ◽  
Cerebral Microdialysis ◽  
Invasive Technique ◽  
Human Brain Tissue ◽  
Protein Patterns ◽  
Molecular Weight Range ◽  
Two Dimensional Gel Electrophoresis

Abstract Background: Cerebral microdialysis (CMD) is a minimally invasive technique for sampling the interstitial fluid in human brain tissue. CMD allows monitoring the metabolic state of tissue, as well as sampling macromolecules such as proteins and peptides. Recovery of proteins or peptides can be hampered by their adsorption to the CMD membrane as has been previously shown in-vitro, however, protein adsorption to CMD membranes has not been characterized following implantation in human brain tissue. Methods: In this paper, we describe the pattern of proteins adsorbed to CMD membranes compared to that of the microdialysate and of cerebrospinal fluid (CSF). We retrieved CMD membranes from three surgically treated intracerebral hemorrhage (ICH) patients, and analyzed protein adsorption to the membranes using two-dimensional gel electrophoresis (2-DE) in combination with nano-liquid mass spectrometry. We compared the proteome profile of three compartments; the CMD membrane, the microdialysate and ventricular CSF collected at time of CMD removal. Results: We found unique protein patterns in the molecular weight range of 10-35 kDa for each of the three compartments. Conclusion: This study highlights the importance of analyzing the membranes in addition to the microdialysate when using CMD to sample proteins for biomarker investigation.

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